※ [本文转录自某隐形看板] 作者: charater ((￣y▽￣)σ推广会会长) 看板: (某隐形看板) 标题: Re: [课业] EF组现在run NOR的同学看过来～ 时间: Wed May 5 20:40:34 2010 明天有摸咪 讨论的case如下: 有兴趣的同学可以准备一下 Dx: 1. Hemangioma 2. Generalized petechiea, suspected congenital infection 3. Suspected meconium aspiration syndrome <Birth history> 1. Birth history: G1P1, GA:37+2 wks, BBW: 2344gm, NSD, perinatal insult (-), 2. Vaccination: BCG (+), HBV(-) 3. Growth and development: BBW: 2344 gm ( th percentile) BL: 44 cm ( th percentile) HG: 31 cm (75-90th percentile) 4. Feeding: HM/IF q3h as tolerate 5. Maternal history: (1) Prenatal exam : no abnormally (2) Radiation exposure during pregnancy: denied (3) Maternal systemic disease: Denied infection or drug use during pregnancy. (4) HbsAg (-); HbeAg: (-) (5) Maternal vaginal GBS colonization(+)during prenatal examination 6. New born screen: pending <Present Illness> The just born boy was born to a G1P1, GA37+2 weeks with BBW 2234gm via NSD. The Apgar score was 7-9. The perinatla course was smooth and he ahd spontaneous crying. After birth, meconium stain 2+ was noted. Generalized petechiea over face, trunk and back was noted. There were also generalized ecchymosis over back and hemangioma over forehead. The prenatal examination was normal. Under the impression of r/o meconium aspiration and generalized petechiea, he was admitted ti NOR for further care. BH: cm BW:2.344 kg General appearance: fair Activity: well HEENT: grossly normal, AF: 2x2fb, soft, no bulging, molding(-), No cephalohematoma conjunctiva: not pale; sclera: icteric; pupil: isocoric Neck: supple Chest: symmetric expansion, breathing sound: bilateral clear Heart: regular heart beat. Murmur(-) Abdomen: soft and flat, no tenderness, Liver, spleen: impalpable, Bowel sound: normoactive Back: no sacral dimpling Extremities: freely movable, no petechiae, no skin rash, no edema Skin: petechiea over face and trunk, ecchymosis over back Reflex: Moro(+) , Grasp(+), Sucking (+) 趋势图 项目 数值 单位 标准值 说明 ViewCond. RBC 3.47 M/μL ♂: 5.2 ± 1.0 , ♀: 4.6 ± 0.9 HB 11.5 g/dL ♂: 15.3 ± 3 , ♀: 13.3 ± 2 HCT 37.4 % ♂: 46 ± 7 , ♀: 40 ± 7 MCV 107.8 fL 89 ± 10 MCH 33.1 pg 30 ± 4 MCHC 30.7 g/dL 33 ± 3 PLT 61.0 K/μL 220 ± 100 PS WBC 17.76 K/μL 7.5 ± 3.5 RL BLOOD No:1002780 ( 99.05.05 14:00登记) (99.05.05 14:26报告) 　 趋势图 项目 数值 单位 标准值 说明 ViewCond. T-BIL 5.06 mg/dl 0.2-1.2 L1H1I4 D-BIL 1.83 mg/dl 0.0 ~ 0.4 L1H1I4 AST 52 U/l ♂ < 37, ♀ < 31 L1H1I4 ALT 11 U/l ♂ < 41, ♀ < 31 L1H1I4 Na 144 mmole/l 135 ~ 148 L1H1I4 K 3.0 mmole/l 3.5 ~ 5.3 L1H1I4 Cl 115 mmole/l 98 ~ 108 L1H1I4 Ca 1.41 mmole/l 2.02~ 2.6 L1H1I4 P 3.6 mg/dl 2.5 ~ 4.5 L1H1I4 Mg 0.53 mmole/l 0.7 ~ 1.03 L1H1I4 RL BLOOD No:1011151 ( 99.05.04 16:14登记) (99.05.04 16:30报告) 　 趋势图 项目 数值 单位 标准值 说明 ViewCond. PT 15.5 sec 8.0-12.2 PT Cont 11.4 sec PT INR 1.51 PTT 41.3 sec 26.9-36.3 RL BLOOD No:1011147 ( 99.05.04 15:53登记) (99.05.04 16:05报告) 　 趋势图 项目 数值 单位 标准值 说明 ViewCond. RBC 4.28 M/μL ♂: 5.2 ± 1.0 , ♀: 4.6 ± 0.9 HB 14.4 g/dL ♂: 15.3 ± 3 , ♀: 13.3 ± 2 HCT 47.3 % ♂: 46 ± 7 , ♀: 40 ± 7 MCV 110.5 fL 89 ± 10 MCH 33.6 pg 30 ± 4 MCHC 30.4 g/dL 33 ± 3 PLT 23.0 K/μL 220 ± 100 recheck PS WBC 12.94 K/μL 7.5 ± 3.5 corrected data Blast 0.0 % Promyl. 0.0 % Myelo. 0.0 Meta 0.0 % Band 0.0 % (band+seg) 40 - 75 Seg 25.2 % (band+seg) 40 - 75 Eos. 2.2 % 1 ~ 6 Baso. 9.0 % 0 ~ 1 Mono. 7.2 % 2 ~ 10 Lym. 56.4 % 20 ~ 45 Aty.Lym. 0.0 % PlasmaCell 0.0 % Normobl. 53.0 /100WBC PS 分类异常 RL BLOOD No:1002141 ( 99.05.04 15:52登记) (99.05.04 16:25报告) 　 趋势图 项目 数值 单位 标准值 说明 ViewCond. C-Reactive Protein 0.02 mg/dl < 0.8 L1H1I2 　 YM Arterial Blood No:0710004 ( 99.05.04 20:06登记) (99.05.04 20:09报告) 　 趋势图 项目 数值 单位 标准值 说明 pH 7.401 * 7.35~7.45 pCO2 36.1 mmHg 35~45 pO2 84.8 mmHg 83~108 --

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